Dr. Tonse Raju: A “fantastic specialty”

Dr. Tonse Raju reflects on his career in neonatal medicine, the advances sparked by NICHD, and on how a surprise package sent from NIH to his dorm room in India changed his life.

Dr. Tonse Rajujoined the NICHD in 2002. He serves as the program scientist and medical officer for the Pregnancy and Perinatology Branch’s portfolio of neonatal research grants, training grants, and Small Business Innovative Research/Small Business Technology Transfer programs.

Q: As the program scientist/medical officer for the Pregnancy and Perinatology Branch, you have an insider’s view of the latest and greatest perinatal research. In your view, what are some of the most exciting discoveries that might transform perinatology as we know it?

Dr. Tonse Raju: There are a few things that are being done. There is treatment for pregnant women to reduce premature birth by administering progesterone injections. Progesterone vaginal suppositories are also being tested to see if they reduce prematurity rates.

What is needed in the neonatal field? I would like see the development of advanced noninvasive technologies that can be used to monitor, diagnose, and treat newborn infants and reduce—infants in ICUs [intensive care units] undergo numerous invasive procedures, most of which produce pain, and we know that long-term consequences of pain can be very bad for the child’s developing brain. A sick baby in a neonatal ICU might need several IV [intravenous] lines for medications and fluids, arterial catheters to monitor blood pressure, and a respirator to support breathing. These treatments and monitoring devices can cause pain. If we can develop noninvasive instruments and devices, that would be a major step forward in minimizing the pain and distress in babies who are already suffering from serious medical and surgical conditions.

Q: Why did you choose to specialize in neonatology?

Pediatrics was my first choice many years ago. I had already been trained in pediatrics when I came to the United States [from India] in 1972, and neonatology was evolving as a fantastic specialty. There had been a lot of intensive care developing around that time. Babies who had been not able to survive now could. I found it very interesting and challenging—and very promising.

Q: Why did you choose to focus on research as opposed to clinical work?

Research has always interested me, I don’t know why; maybe my curiosity and trying to find answers to questions that I could not easily find. So that led to my interest in research. Even as a medical student, I was doing research during my rotations in clinical services; it was fun. In India, we had to do research for our thesis as part of our pediatrics M.D.—it is like a masters degree in pediatrics one does after 3 years of basic medical degree, which is called MBBS.

I have a fascinating story: I wanted to do research on what is called atypical tuberculosis (TB)-a recently discovered, newer strain of TB bacterium. I read a paper about its classification in a journal called the American Journal of Tuberculosis Medicine (now called the American Journal of Respiratory Medicine). I thought to myself, "This is from America, this description of the atypical TB. There is so much TB in India. Why not do a study here [in India]?"

You needed special antigens to do the study, and we didn't have them in India, so I sent a hand-written letter to the first author of the paper. I said, "I am a postgraduate student, I would like to do this study, and if you have these antigens, can you send them for skin testing of Indian kids?" Then I forgot about it. Four months later, after no reply from America, I was astonished to see a big box sitting in front of my dorm room.

So I opened it, and there were all the skin testing antigens I had requested. And then I opened up a letter and discovered it was from the National Institutes of Health, from Dr. Lydia Edwards, the first author on the paper I mentioned above, who was the director of the tuberculosis division in the Heart, Lung, and Blood Institute of the NIH! She had written, "Good luck with your research." I was so thrilled! Someone unknown to me had sent me this in response to a meager hand-written letter. So of course I did the study. We were the first from Mumbai to do the study on atypical mycobacterial infections in children in India. We published a paper and so on. That was fun!

Q: What do you see as the most important challenge-or, perhaps, challenges-that, if solved, could improve the health of newborns and their life trajectories?

In this country, and also all over the world, [the most important challenge] has to be prematurity. We need to reduce the prematurity rate. Even [the babies] who survive have long-term medical needs. Some of them have neurological problems. The burden of prematurity is huge: There is the cost of suffering to the baby, the mother, the father, and the family, [and] huge health care costs to the society. Preterm babies end up getting hospitalized during their childhood about 10 times more often than normal-term babies. The annual cost to society of preterm birth in the U.S. has been estimated to be at least $26 billion.

Q: You're about to have your tenth anniversary at NICHD. How has NICHD's perinatal research portfolio changed and evolved in the past 10 years? What is possible now that wasn't 10 years ago?

We have a lot more people who have joined the branch [since I began at NICHD]. There's a new portfolio on obesity that my colleague Dr. Caroline Signore is working on. She's an obstetrician. Also there's a new network called the Stillbirth Collaborative Research Network. I'm working on the Community Child Health Network. It is major research involving five sites and about 2,500 women and about 1,500 of their partners. The study is in its final stages of completion.

In the Community Child Health Network, we are trying to find the reasons for disparities in health outcomes, using a model called community participatory research. The community members are actively engaged in developing research protocols and all aspects of the research progress. We enroll participants during their postpartum period. We monitor and measure their stress levels using a variety of methods for about one year and, in some of them, until they get pregnant again.

We also assess the safety of their living environment. If you live in a place where, when you walk to the grocery, and someone shoots at you and you're pregnant, it's not going to be very healthy environment either for you or for your baby inside. We are trying to determine not only whether such stressors happen, but also what are the consequences of such stressors on the body, and how such changes lead to bad outcomes, which to some extent may explain the existence of health disparity in perinatal outcomes.

We know that not everyone who has these kinds of challenges will have bad outcomes. So then how can those few people cope with it? What are the mechanisms of resilience? So we are also studying resilience among African Americans, Hispanics, and whites, both rich and poor groups. It's great data, a very nice study. This is actually the first ever community participatory research project in neonatal medicine.

Q: About 10 years ago, you published a book of South Indian proverbs. Why do proverbs interest you?

There is tremendous wisdom in the proverbs. There are actually proverbs about proverbs. One proverb says that proverbs are as good as the Vedas, the ancient Indian scriptures like the Bible. Another proverb says that a proverb in your speech is like chutney in your food. They add spice. Proverbs come from ordinary folks.

Q: You have a strong interest in medical history. What is it about medical history that interests you, and does this interest inform your work at NICHD?

Medical history is, first of all, a human story. It is our history. We learn so many things from when we make mistakes.

I read medical history as I read stories and novels. I'm interested in fiction and writing. When I was in medical school, editing the school magazine, my professor wrote a small paper on the history of doctors' fees. It was fascinating. He quoted Hammurabi's code, which lists what kind of fees doctors would get and what happened if the doctor mismanages the patient-what kind of punishment would he get. The fees were based on whom he was treating. Was it a slave? A slave owner? A merchant? Each one has a different fee structure. It was funny and interesting.

Q: What's an example of something you have learned from medical history?

The process of discovery is very complex. You almost never have a "eureka" moment-that's very rare. Discoveries have happened when a mind is prepared. One has to be having an insight to be able to find things. I always tell students that thousands of apples have fallen on people's heads, but the head would have to have Newton's brain inside in order to have the insight-if that story is even true! Probably it's not.

Q: Imagine that you are in a concert hall filled with future parents and you have five minutes to speak to them. What would you tell them?

It's a great thing to have a child. And the sooner you have them the better. Second, what a mother can give and what a father can give, no one else can give. Doctors cannot give what parents can give. So from the very first day and onwards, make sure the child is wanted. And I would strongly recommend breastfeeding. I would tell them that breastfeeding is not just serving meals from a breast. It is an actual interaction. It is a hard-wired interaction. It's a physiological interaction, the same way the placenta is interacting with the fetus and the mom. It is the only physical interaction the baby has after coming out. I would tell them that if there is a problem with breastfeeding, they should consult someone who can help them. Don't give up right away.

Finally, raising children is not easy. I want to tell parents to be realistic. It's not utopia with Beethoven music in the background. There are hardships and there are tough times and you've got to be prepared. And the problems keep changing. When the kids are teenagers, there are different kinds of problems. Don't demand anything from your child, but at the same time, you can be a strict disciplinarian. You have to make them feel comfortable that you love them. When that happens then you can be strict also.